SCCM Resource Library-Quality and Safety in the ICU: How Facility Design Influences Critical Outcomes

Video Transcription

All right. Good afternoon, everyone. Thank you very much for coming. This is our session titled, Quality and Safety in the ICU, How Facility Design Influences Clinical Outcomes.  And my name is Jason Hecht. I'm a critical care pharmacist at St. Joseph Mercy Hospital in Ann Arbor, and currently an ICU design committee member  where this presentation has come from. And I'm proud to present our first speaker today, Sandy Swoboda, who comes from the John Hopkins School  of Medicine, as well as nursing, and one of the co-authors on the ICU design guidelines. And she's going to be presenting first. All right.  I would like to thank everybody for not being at the pool and being here. I know there are other things to be doing besides this. So that was a good moderator move.  Just wanted to say, how many people in the audience are architects? Any other architects in the audience? Physicians? Nurses?  How many of you have redesigned or reordered your ICU recently? How many of you are thinking about it? OK, so good for a number of hands. So what we're going to do today is  I'm going to kind of go through these objectives. I have nothing to disclose on my part of the talk. But I'm going to start walking you back a little bit  historically about thinking about what's important about the ICU and design and layout from it. So we all remember that the Institute of Medicine in 1999  put out the two errors human. And it showed us that patient safety was a big problem in our health care. And we needed to do something about it.  They followed that report up with the Crossing the Quality Chasm, a system for the 21st century. And this paper looked at these six specific aims  as ways that we could improve health care delivery and outcome for our patients. And so if you look at what these aims are,  patient-centered care, safety issues, infection prevention, lighting, which can make the ICU environment more effective, efficiency in our delivery of patient care  also includes not the protocols that we do and the people that we hire, but how the form and function of the unit is laid out, timeliness  to ensure rapid response to patients, and equity in size and layout. So as you, for those of you who have redesigned and those of you that are thinking of it,  you have confines to work with within sort of the scope of your space. And so design can have a big impact on patient outcomes. So poor design, if it's loud and noisy,  there's limited space for families. This challenges our ability to deliver good quality care to our patients. Good design elements include things that help promote patient healing.  If it's quiet, there's less distractions, patients can rest better, staff can concentrate better, we can think about what it is that we need to do  to provide for our care of the patient. And having an opportunity for families to be present makes a big impact on this.  So think about this. Florence Nightingale in the mid-1800s, she identified noise, light, ventilation, and cleanliness as things that would impact patient care delivery.  We are still talking about these things today. There are guidelines in place that we published in 2012 that are evidence-based in the architecture world  about recommendations about how to design an ICU, what's important, what are regulatory issues. And so this serves as a guide to help us think about  what we need to do when we build our units. Literature reviews have shown us that the layout is important, patient care delivery, how visible patients are, how accessible they are,  are important, and communication and staff satisfaction. All of this plays a big role in how our patients are going to recover and what's going to happen to them.  So historically, if you think about the design or the ICU layout, there are some considerations to think about. What shape is the nursing unit gonna be?  And I believe Charles is gonna talk us a little bit about the different shapes. It could be a circular shape, it could be pod-shaped, it could be linear.  What does the overall design of the ICU look like? And how close are staff to the patients? And how fast can staff get to the patients when there is an emergency situation?  What is the nursing station layout? Is it a centralized type of a nursing station where everybody congregates? Or is it decentralized where the nurses  are at the outside of the patient's bed? This makes an impact on how we can deliver care to our patient. And then what about where our equipment is located?  Can we get to a patient with emergency equipment quickly or do we need to have multiple access points for this?  This then lets us think about what's important for the ICU patient room. ICU patient rooms are generally divided into three different zones.  There's the patient zone, there is the family zone, and then there's the staff zone. The patient zone is here where the patient is on the bed.  If you have your medical gases on a headwall system, then the patient's bed is up against the headwall. If the gases are in a boom type of a situation  that either comes from the ceiling or from the floor, then the patient's bed can move around the room depending on the size of your space. So in thinking about the patient zone,  how do we get around the patient's bed? How do we get access to the head and the foot for emergency situations? And then can the patient get out of bed?  Mobility is a big issue with our patients and we have new equipment that comes in to help patients move out. Do we have enough space to be able to get the patient  to move away from the bed? The family zone is important because this is space that's close to the patient, but it's out of the way of the staff, okay?  So in thinking about your ICU rooms, how this works, and it allows for visibility of the patient and the family can also see out into the hallway.  And then of course, there's the staff zone, and this is where the staff spend a lot of time.  We all know that computers are now part of our bedside footprint. So we have to think about where does the computer fit in a patient's room?  Where is this in relation to the barcode scanner, med prep area for the nurses, and equipment that can be readily available to take care of your patients?  So what I'm gonna do in this next several slides is kind of touch on some things in the literature that address some of these problems.  So the first thing I wanna talk about is noise. And if you look in the literature, there are articles and studies that have been done that look at the impact of noise.  And noise doesn't just impact the patients, but it impacts us as staff and care providers. The WHO recommends that the noise level should be less than 40 decibels.  Several published studies that have looked at noise in ICUs say that about on average, it's about 60 decibels. So for frame of reference, who vacuums?  Who's heard of vacuum cleaner? Those are around 70 decibels. Okay, so if you think about the noise that we're exposed to on a daily basis,  or that we ignore, what does that do for our patients and our physiologic response? So people have studied this. Heart rate goes up, blood pressure gets affected,  it's disruptive to sleep, and some studies have shown that noise can impact delirium. And not only for our patients, but what about the impact on staff?  How many of you can concentrate when you're hearing a lot of different noise impacts coming in? I know a lot of us can multitask, but can we concentrate on the things  that are very important, like preparing medications?  Noise can also lead to miscommunication between staff. So articles are out there, and interventions that we can do are helpful to help us with this issue,  but some of them are not well proven. And it's hard sometimes to know how noise really does impact a patient's healing, but it's something we need to consider.  Medication safety. This first study is a single site survey of 84 nurses and looked at what is important for you about preparing your patient's medications.  And the biggest complaints they had were inadequate space for charting and documentation, how far away the med room is to the patient, what are noise levels and lighting?  And recommendations from some of the literature is that we should have a standardized setup for medication, there should be a safe zone, lighting should be good,  and it should be a place where you're not distracted.  With the onset of Epic and Cerner and patient bedside barcode scanning, we now have to have a place in the patient's room for the barcode scanner.  And how we deliver medications today is very different than how it used to be. So in the old days, you'd go to the med room, you'd grab all your meds, you'd go to your patient,  you'd check their name band, you'd give them all their meds and then you'd sign them off. Now what you have to do is you have to have a space  to open up the computer, get the barcode scanner out,  scan the patient, go back and scan the med, check on the computer that this is the correct med, sign that off, then go give that med to the patient.  Then you have to go to your next med and do the same thing over and over again. So that repetitive action in motion can be an issue, so that's why in the staff zone  there should be a dedicated space for us to think about how we can deliver these meds and decrease safety issues. So this all leads into issues with employee health  and quality of life as you are caring for your patient. So if the environment is not conducive to a good work environment, it can lead to errors, work-related injuries,  call-outs, burnout, that type of thing. So we sort of think about that as you're going through your design process. Now I'm gonna switch gears and talk about nosocomial infection.  These elements listed here are key elements to consider when thinking about infection and what we can do about the ICU and the design of it to help cut down our infection rates.  Ventilation systems are important, temperature, humidity controls. One thing I think is very interested on here is many ICU rooms in the past did not have toilets in the room.  When you think about this,  now there is a toilet in a patient's room and it may be hidden behind a curtain or it may be tucked underneath a countertop, but the spray from when you flush that toilet  goes up into the air and permeates the atmosphere. How far away the sink is from your patient's head of the bed, right, makes a big impact.  In the old days when the rooms were small, the sink was right next to the patient's head of the bed. How did this contribute to our nosocomial infection,  pneumonia rates, that type of thing, from splash from just turning on the sink. So thinking about these elements of your design are very important.  This study, and there's several studies published, looked at the difference between a single patient room and the layout of an ICU that has multiple patients,  is also known as an open ward or an open bay design. Systematic reviews have shown that there's significant benefit of single bedrooms and there are some studies that have showed  that there's been no impact on nosocomial infection rates in open bay rooms. So the rules may be different in the US compared to other countries  about single private rooms versus open bay. So be cognizant and aware of what some of the issues can be. This meta-analysis that was published  showed that colonization and infection rates could be impacted and that the recommendations favor a single patient room design.  Now let's talk about the neonatal ICU patient. If the patient is in an open sort of a layout, as many little NICUs are, where you see the patients sort of lined up  next to each other, versus patients being in a private room.  There's 13 studies that are published on this and in an open ward design, there's overstimulation from noise and light, okay? So whatever's happening with this baby over here,  this baby over here gets impacted from it and if there's a lot of people taking care of whatever emergency situation this is, this can have an impact on the other patients.  However, it's ease of visibility of other staff  and access to the patients. So you can stand in one spot and see everything that's going around, versus single patient rooms with the little babies.  I can't see into those rooms, okay? Where is the nurse taking care of that patient? So studies have shown in single patient rooms that family presence leads to faster baby growth  and earlier discharge because there's a space for the family to be if the patient's in a single patient room. But these patients also can develop language and developmental delays  because perhaps there is no family to be present and there is no external stimulation from the noise. So there's a little kind of a catch-22  when you're thinking about this.  Okay, let's talk about delirium. Delirium rates, we know, is anywhere up to 70% in our patient population. There are many things we can do about delirium  in helping take care of our patients, but what about the design of our ICU? The jury is still out about the impact that it can have. Retrospective single center studies in Brazil  and the Netherlands showed that delirium prevalence can be lower in patient private rooms, but that the delirium-free days is no different. So what recommendations are coming out  is that we need to create an environment that can engage the patient, that can promote interactions with others, empower their mobility,  and try to put them into a normal sort of situation even though they're very sick. So having windows and natural light and distraction is really important to help with delirium.  And as I sort of wind down this walk through the literature, I'm gonna talk a little bit about centralized versus decentralized nursing stations.  Okay, so I talked a little bit about it earlier. Centralized station is where everybody kind of can get together, chart, see each other, talk about the patients, et cetera.  But there's been a big move toward to decentralizing nursing stations and putting the nurses outside of the alcoves of the patient. So if you look at this picture here,  it is a 20-bed unit that is in the middle of the morning. What do you notice?  It looks like an empty building, like there's no one in the hallway. And so with decentralized nurses station, having the alcoves outside the patient rooms  has put the nurses, in some studies, increased their time of care for the patient. They have decreased the number of falls for patients  because the nurses are closer to where the patients are. Job satisfaction seems to be better for some staff because they don't have to walk as far.  I don't have to expend as much energy  because I can be right there for my patient. And the patients report that it has a positive impact on them and same for the families because they see the staff members right there.  However, there are unintended consequences with a decentralized station.  It's inability to see everything at once. So if this is a U-shaped design hallway, we can't see what's happening on the other side. I have no idea who is also working on that shift.  There's fewer opportunities for staff to network with each other or talk about what's happening with our patients. So there's a social isolation and a silo effect.  And then there's some safety issues. If I am here and I go into my patient room because there's an emergency, nobody else is gonna know what's happening  because everybody else is in their little alcove or in their little spot to help take care of patients. So these are some important things to think about how we as humans  interact with our environment. This last study I wanna talk about talks about staff communication. This first one looked at the physical environment  and they interviewed staff about how do you communicate? Where do you go and talk to each other about your patient or about issues that are happening?  And the staff didn't go to the places that everybody thought they were gonna go to. They went to different places on the floor because they were worried about privacy issues,  safety issues about what they were talking about and whether or not they felt they were connected to the patient and what issues they had to discuss.  And then this last study looked at the relationship between a nurse and a nursing tech and how do they communicate now that there's a decentralized nursing station  and the nurses are at the different alcoves taking care of patients. And they found from this that the spatial layout really did impact communication.  Even though we have devices like locators and phones in our pockets, the communication was worse than it was when it was in a centralized sort of a fashion.  So the other thing that happened was there was more communication occurred inside the patient rooms. So we all know that this happens. You're in the room taking care of a patient,  your phone goes off, you start talking about the other patients or the other issues in front of that patient that you're with. So the design and the layout of these things  have implications for what we need to be doing to deliver good quality care for our patient. And sometimes it can have a big impact on our patient's outcome.  So in conclusion, I'm gonna let our next speakers talk, but what I tried to walk you through a little bit was that evidence is building and growing  that design can impact our patients and can have an impact on our outcomes. And that we need to continue to study this  in as much formal fashion as we can to get some research out there to see what impact these things have and look to the past and the current  to figure out what we're gonna do for the future. And with that, I will turn it over to our next talk.  Thank you.  Our next speaker will be Charles Cadenhead, who's the Senior Medical Planner at EYP Architecture and Engineering and a longtime member of the ICU Design Committee  here at SCCM, as well as the current chair. We're very lucky to have him and hear from him today.  I think I'm the only architect in the room, so that's safe, maybe.  What I'm going to talk about are trends and things that we've observed over the course of the Design Awards program,  which is supported by SCCM, the ACCN,  I always screw that one up, the Critical Care Nurses Association,  and the American Institute of Architects Architecture for Health Committee.  This program started in 1992, and it continues up to today. So we have quite a bit of data, and meaning plans, programs, photographs,  tours that have been made of these units where possible in order to begin seeing what they represent. As was stated by Sandy,  there's lots of different shapes for patient care units. There are double-loaded corridors, which are called linear here. This is a unit at McGill in Canada.  There are pods where an overall unit is divided into groups of maybe six or eight or 10 rooms. There are racetracks, which seem to be predominant.  There are a lot of units which have this general form. The two units that were awarded winners,  and a honorable mention this year, both represent the racetrack type of unit. And there's kind of a mixed, where you bring aspects of more than one shape or geometry to the design.  What this tracks is the square footage per bed across time,  from 1992 to the units that were selected for awards at this SCCM Congress this year. You can see that the top light blue line, which has a lot of variation in it,  is the departmental gross square feet per bed.  By saying departmental gross, it's what architects would usually call it, it's usable square feet. It's square footage that you can take advantage of,  that you can put a program in it, people can work in it and use it. There's a lot of other square footage that goes into a building. Information technology, electrical, mechanical,  and so forth. But this is tracking the usable square footage. You can see a great range. Probably the highest one is almost 1,400 departmental gross square feet per bed.  That's the biggest one on a per bed basis.  This year's winning unit, which is Texas Children's,  in Houston is 1,280 departmental gross square feet per bed  for a pediatric intensive care unit. And you can see the wide variation between that and a neuro unit that was for adults and was recognized as the second place unit,  which is down at 790 square feet per bed. So there's a big range there, and there's a big difference in the program, room size, equipment, and so forth.  The patient rooms themselves don't vary that much. That's the dark blue line running across the bottom.  From 1992 up to today, patient rooms have gotten larger  than they were, although not so dramatically. We'll look at some images that explain a little bit of why that is. Part of it is family participation in the patient room.  That's a big part of it. These are the trends I'm gonna talk about very briefly for the sake of time. Why units are larger than they used to be,  patient rooms, family space, technology in the rooms,  interdisciplinary teams and how that gets reflected in design, diagnostic and treatment, equipment and spaces that are near the unit or in the unit, integration of administrative  and support spaces, geometry, circulation, and views to nature and the importance of that.  SCCM started, I think, in the early 70s. Back at that point in time, most ICUs were very much like a recovery room. Many of them were recovery rooms and they were then used  as ICUs, intensive care units. Over time, that has changed dramatically. You can see that the square footage, that usable square footage per bed has approximately  and a bit more doubled over time.  Why is that? Some of that is due to things that are outside of the patient room. They deal with things like corridors and circulation.  The far left image comes from Emory's  neuro-intensive care unit. It was a winner in 2008 of the design award.  And they, in rounding on the floor,  they do a very physical rounding. Not every place does that, where they move residents and fellows and nurses come out of the rooms and they talk to everyone.  Owen Samuels, who's in the photograph sitting,  has his table with screens so that he can bring up the most recent CAT scans or MR images. The next two images come from Neil Halperin, who's our third speaker, from his unit  when I rounded with his staff at Memorial Sloan Kettering.  The advent of computers on wheels has led to space needs. When they do rounding in his unit, it's incredible. There's probably 10 or 12 of these computers on wheels  that are rolling around with people and it gets very crowded. And I'm at the back of the collection of people that are rounding. I couldn't hear hardly anything that the physician  who was leading the rounding was saying because of the stacking up of people. What works really well in Neil's unit is that the corridors are wide to start with.  They're more like 10 feet wide rather than the minimum of eight feet wide. And they have deeper alcoves toward the patient room in addition to that.  So it allows people to gather up, get as close as they can, and talk. Also, in some units, there is some ambulation of patients  that can get up and walk within the unit such as you see on the far right.  The patient room itself, they seem, rooms have seemed to have stabilized at about 250 to 300 square feet per room. That is beyond what your normal building codes  or state regulations will say. Those are almost always minimal. And often their title, minimum standards. And if you're not careful a little bit, the program, the space program  from which your designer will work will start with minimum standards that may or may not work for your hospital and the kind of patients that you have.  Family space can range beyond what you see on this slide. 50, 65, 80 square feet for sleeping, couches, furnishings for families  that are staying in the room with their family member. That also depends on hospital policy and how that works.  The room being used as a procedure space is a very important aspect of critical care room design. As you see here, they are setting up for a,  I think it was a tracheotomy, in this room at Emory.  You can see all the people in the room. There's anesthesiology, surgeon, nurses, and so forth, and a lot of equipment. It all adds space. For families, again, using Emory,  which is an interesting case study all by itself,  to the left is a pair of patient rooms. In this case, they have added small spaces, about 110 square feet, which is dedicated to the family.  They can sleep there.  There's a hand wash sink. They can brush their teeth. They can wash their hands in that space,  which is immediately adjacent to the patient room itself. In addition to that, there is a collection of family support spaces in the right-hand diagram,  which is everything from children's waiting, adult waiting, a laundry, storage,  consultation spaces, a kitchen, and so forth. The character of this unit is that it's a neurointensive care unit. It has international patients that come there.  They stay here a long time,  and they take full advantage of these family spaces in this unit. A bit of a different approach to family space is in this Dutch hospital.  It's a university teaching hospital in Utrecht, the Netherlands. What you see in the orange circle is the family space dedicated to families. It is six sleep rooms.  It's like a small hotel. Each room does have a toilet, shower immediately attached to it. There's six of them here. There are 36 beds on the floor,  so there's one of these rooms for every six patient rooms, so not everybody can stay here,  but it's a very nicely designed area, and it also provides space where families who have like issues going on can talk and chat and have a cup of coffee  and share their common experiences with each other.  I have yet to find a U.S. hospital that wanted to go that way. I bring it up. I talk about it, but so far in the U.S., it's more family members being accommodated  within the patient room rather than outside of the patient room. Technology and life support systems varies a lot.  It has different demands on space. This is Memorial Sloan Kettering. I will say that Neil has been a real groundbreaker when it comes to the patient room  accommodating almost every kind of technology that you could think of. He has probably added some, and he'll talk about those, I'm sure,  to the point in time that this photograph was taken with the list of technology that's within that room.  There's also the more portable and robotic kinds of equipment, whether it's handheld, actual robotics, or again, computers on wheels that take up space around the unit.  Interdisciplinary design teams is a big thing, takes a lot of space, people getting together. I've always thought that this 2001 winner is interesting in that they are six-bed pods  around this square, and within each of those six-bed pods, you'll see in the color to the left side of the plan, on the left,  you'll see where there's space for nurses and physicians to gather up immediately outside the patient room, but also in the middle of that grouping.  To the right is kind of a cockpit area for Emory,  where it's large. Three or four people can sit there and talk about a patient in one room or the other.  Proximity to diagnostic and treatment is something that has grown over time.  This is the very first winning unit. It's in Denver, Colorado. There are two 16-bed groupings that you see in these almost square, chamfered square groups,  and immediately outside of the unit are the cardiac cath labs.  This is a general medical-surgical ICU. The cardiac beds are right in here,  and so they are closest to these cath labs if they need to take advantage of them.  Administrative and support space, again, this is Memorial Sloan-Kettering. It's a great example. The sort of yellow-green are offices, residence fellows, conference room,  teaching space, and so forth. Respiratory therapy immediately across the corridor, and dialysis here in the unit. A clever thing that I think was done in this unit  is that these dialysis rooms, so I was told, have been set up to where if the unit is full and they need to move a patient in in the middle of the night,  they can put them in these rooms because they have all the utilities that are required until that next bed opens up, and they can put the patient in a proper patient room.  Again, configuration, there is no magic shape or form. These can be U-shaped, L-shaped.  Someone, maybe Sandy, mentioned circular. It's been a long time since I've seen a circular unit, which is not a great thing.  I see people, every time we start a new unit, usually the staff come in and say, we'd like a circular unit.  Part of what has occurred is that  nursing units in general nowadays, you rarely, rarely find a circular unit.  The units stack in tall buildings, and they have to assume the shape and the form of the building. And for those reasons, you don't see the circular form very often anymore.  Segregated circulation. This is, I think, a great and very clever solution in a very tall, urban building. This is Lurie Children's in Chicago. It is a vertical hospital.  What you're looking at is one floor slice in that building. There are 14 elevators. There are two groupings of patient and materials and supply movement.  And then there are four elevators that serve visitors, family, to the unit. The yellow shows you where the initial family circulation starts.  The orange shows you circulation which is dedicated to physicians, nurses, and materials offstage, meaning not intermingled with the general circulation in the corridors outside  patient rooms. And the blue is where families, patient movement, and physicians and nurses, when they're attending  to patients where they circulate. But it was a very well done core design and circulation design, I think, in that building.  Access to nature is something we all, I think, intuitively feel is a great thing. It can be difficult to achieve. This is an interesting unit. It's an older unit.  It was done not long after the design awards program started. It's from 1996. This is a room that had one of the early pendant ceiling hung medical utility systems in it.  And what that did was free the walls around most of the room from plugs and sources for medical utilities, which meant it could be glass.  This was a unit built on top of a low-rise parking garage. It was done by an architect who had never done another healthcare building and retired shortly after doing this one.  But it's a very interesting unit. I think you can see the floor plan, which is small, but you can see the string of rooms that run like this. They look out through the glass.  From the nurses here, they said one of the encouragements they could make to their patients was if you get better, we'll take you out of the room onto the rooftop to be outside.  And it was a great encouragement. How many times they actually were able to do that, I don't know. But for them, it was important.  I think the outside access was important to staff and very important to families. And if nothing else, the encouragement was very important to the patients.  Doing green space in tall buildings is a challenge. This is not an SCCM winner. This is one of my projects.  But I wanted to show it just because we worked in the very beginning of this project to work out green areas for families.  They arrive in an elevator core here and then there's a green roof outside of the corridor that takes you back to the nursing unit.  That's what families can come back and out on the roof. And this is for staff. The staff break areas are right here. And this is a terrace that allows them to come out on the roof.  And from here, they're in Stamford, Connecticut. From here, they can see New York City on the horizon from this fourth floor terrace. So in tall buildings, you can do this.  In Houston, I'm doing a 28-story building tower, but we have a green roof that is immediately outside critical care in that situation.  But you've got to start right off the bat planning to do those sorts of efforts. And with that, these are the trends. And I'll turn it over to Neal.  All right, and last but not least, we have Dr. Neal Halpern, who's the Chief of Critical Care Medicine Services and the Director of the Critical Care Center at Memorial Sloan  Kettering. Thank you all very much for coming. Thanks to SCCM for putting together this program this afternoon.  So I was asked to talk about what was learned and changed in 10-plus years since winning the ICU Design Award, some disclosures. So what's new since winning the award?  The answer is I'm older. I don't know what to do with everything else. And Phil Barry's older. So today, there is less privacy, too many hackers, social media gone crazy, too many  devices, and too much data. Computers are too intelligent. And the world is a more dangerous place from the aspect of increased natural disasters and increased human disasters.  So we're not going to talk about the bricks and mortar of the ICU. We're going to talk about how to address these issues.  So we're going to look at privacy, both local at the patient level and digital, cybersecurity,  something called dark data, artificial intelligence, machine learning, which has been a big part  of this year's Congress, disaster planning, threat management, and a concept called future-proofing.  So here is our patient room. We have our patient. We have all these people in the room. And the most common way privacy is provided is through a glass door.  So the question is, how do we provide privacy when there's a clear, transparent glass? So still commonly, there are curtains, a very problematic solution.  Another approach is slats in the double glass, and that could be run manually or electrically. And what we and my friends in Utrecht have were electronic glass or e-glass.  So what about digital privacy? We have our patient. We have our electronic medical record. We have medical devices, and we have something called the cloud, whatever the cloud is.  So the patient, of course, produces a lot of data, and that data could go into the devices or the EMR, and then hopefully it gets to the cloud.  Then we have somebody sitting somewhere in the world who has nothing good to do. So that person looks to encrypt the data so the hospital has to pay them.  That is hacking cybersecurity issues. Alternatively, that person could say, forget it. I don't really care about decrypting the hospital.  I just want to take the data so we have no privacy for patients. This is a real live issue today. Let's look into cybersecurity. We have our hospital in the middle.  We have multiple networks in the hospital. We have medical devices, so-called black boxes. We have hospital employees on email. We have the front door with a big sign, no hackers.  And then we have hackers. So we have a car pulling up on the left. The hackers, they can't get in the front door. They go in the back door. The back door, the medical devices.  And they start sending hacking stuff into the building, and they encrypt data. What about other people? We have hackers all over the world.  They get into the cloud, and they hack the backup data of the hospital. And the last thing is we have email servers phishing. We have emails sent to hospital employees.  And the mistake that we all make, what's this email or web link? Let's click on the link, and bad things happen. Now what happens? Your hospital is in jail. It can't function.  This happens every day in the United States. The administrators get very upset. Let's revert to paper. That doesn't work out well.  So the hackers don't charge a lot, $15,000, $20,000 in Bitcoin will get you your hospital back. And that's what happens. Everybody is kind of happy. The hackers, the hospital.  It's the cost of doing business, and the hackers go look for another hospital to torture. What about something called dark data?  Dark data is data that is produced in the hospital, we'll refer this to the hospital, that goes nowhere. It doesn't get into the EMR, it doesn't get into the cloud.  It may not even stay in the machine. And I'll show you what I'm talking about. This is our 10-bed ICU, and we have somebody doing sonography.  They're going bed to bed, and data is building up in the sonography machine. And they keep going and going. And at some point, the machine says, no more. I'm full.  I have no more room for additional studies. If you keep insisting on doing studies with my memory, which is limited, we'll just overwrite the early data. So what then happens?  We could get the data out of the machine and put it on a USB port. And that USB, this thing, is dark data.  And you see people all over the world walking around with data from machines that gets nowhere.  So optimally, that data should travel to the EMR and to the hospital network and should not remain as dark data. You can't bill it. It is not part of your record.  You have no medical legal approach. Now what about artificial intelligence?  There have been a lot of lectures here. For the purposes of this talk, I'm going to say artificial intelligence, neural networking,  machine learning, deep learning are all variations of the same thing. We want to understand the human brain, and we want to convert it to a computer.  So here are all the typical things in the human brain. And we can acquire a certain amount of data. And we replace that human brain with a whole bunch of computers.  And those computers have a problem with intuition and common sense. It is very challenging to program those two concepts into a computer system.  But the computer system could take liters of data, far more than a human brain could take. And then we could do all kinds of programs and algorithm, and this is the neural networks  and the machine learning and so on. So now this is the computer talking. We're using data, algorithms, neural networks to learn, become intelligent, be intuitive,  maybe interactive, and mostly think like. So the question is think like what? The computer's not sure. So I want to be thinking like a human, or maybe I don't.  Maybe I want to think like an inhuman.  But what I really want to be is a virtual doctor. So there's an ongoing debate going on now all over the world.  And I've gone to several of the AI talks here, and this is a common theme. How should the virtual doctor think? Like a human, we program the AI to do everything a doctor would do.  Thinking the same way, gathering information the same way, we train it. But what about the doctor's instinct or intuition? That's not readily capturable.  Or do we go a different way? Do we say the computers are not human, it's inhuman, no replication of the MD process instinct or judgment.  Let's let the computers be computers and take care of patients in a totally different algorithmic and pattern recognition way. Should we bet the farm on AI? I don't think so.  Not yet. Maybe 10 years or more. What about disaster planning? In New York, we experienced Hurricane Sandy.  We have a lot of big buildings, unlike the unit Charles described where they have such nice places.  If somebody wants to go relax in Memorial Hospital, they've gone to York Avenue and First Avenue. There really isn't any other place to go.  Anyway, the hurricanes come, the elevators are stopped, the buildings shake, and then what do we do? How do we get patients out of here? We can't find the evacuation devices.  We only have two for 20 beds. Where are the rest? They're in the basement. Let's grab the elevators. What? No elevators?  How do we get to the basement and bring all the stuff upstairs? Finally, someone brought them to the ICU. Not enough.  You have to triage who you're going to get out in the middle of this hurricane. This all is real. This happened at Langone Hospital of NYU. How do these devices even work?  I'm going to go down the stairs with the patient and pumps, hope the patient won't break. I hope everything is waterproof because we have to get outside in a storm.  How do we clean them so we can bring them back up and use them again? There's got to be a better way.  That better way is thoughtful preparation for the disaster that may or may never come. This is called your insurance policy. We're going to lose power in elevator transport.  We have to deal with a lot of people. We need adequate quantity of devices that hopefully are locally stored. There are many types of disasters.  These devices should have the following criteria, easy to store and deploy, intuitive, familiar  to rescue personnel that they know how to deal with them, effective, easy to disinfect and reuse, and not be too costly.  In every ICU room in our ICU, we have something called the evacu-pod and something called a mega-mover and a space blanket.  The mega-mover is instead of using the sheet where you have to wind your hand over the sheet, this is a special sheet. And it can hold up to 600 pounds.  It has handles so you don't get burns. And there's a foot pocket so the patient doesn't slide out. And on the bottom right, you see the mega-mover and the patient in the mega-mover.  The space blanket, also known as rescue blanket, solar blanket, mylar blanket, emergency blanket, you wrap the patient in it.  Joggers use this, marathon runners are commonly wrapped in it after their run. And it provides heat retention and compact emergency protection in all weather conditions.  And the evacu-pod, this knapsack, opens up into this evacuation pod. Self-inflating bed, envelopes insulate the patient, carry the patient devices, 500-pound  limit, rescue-grade material, slides, down steps, and floats and holds your temperature. And this is what we simulated, the evacu-pod, the mega-mover.  We get the patient off the bed in the mega-mover, put the mylar blanket on, wrap them, and take them down. We included one other element.  You see this all over the convention center, and that is these emergency chairs that have like a rolling thing that they just slide down the stairs. What about threat management?  So today, we have a lot of bad people. So this guy is coming in the ICU and comes in, raises his weapon, and now what do you do? Threat management is a big deal.  And how could we better handle it? We better handle it through special artificial intelligence scanners.  Person comes in, the person is scanned, the weapon gun contour is seen, the angry aggression face is noted, the door locks down, security is called.  So there are several vendors that do this, and they provide covert threat detection to existing cameras and CCTV, AI algorithms take care of real-time detection of weapons  and aggressive motions, facial appearances, and lock down and send alerts to the appropriate thing, appropriate groups. Let's finish up with future proofing.  So future proofing is the following. I'm building my ICU, spending a lot of money. I want it to last a long time.  So what do I have to do to future proof it, that it will last a long time? And this is very challenging.  Donald Rumsfeld goes through this routine of the no-knowns, the unknown-knowns, the known-unknowns, and finally, the unknown-unknowns.  You don't even know what you're going to address because you don't even know what's coming.  So today, I would say future proofing is about providing electrical power, redundant electrical  power, more than you need when you open the ICU, plenty of wires, and plenty of wireless bandwidth. So in conclusion, in the last decade, a lot has happened.  The ICU now faces extreme threats to privacy, data security, too much data generation, overly smart computers, disasters, and physical threats.  Good ICU design needs much more than nice-looking bricks and mortar to succeed in this environment.  So today, ICU architects, designers, nurse leaders, intensivists, anybody involved in this process will need to be quite knowledgeable in diverse disciplines to maintain the safe  environment of their own ICUs today. And certainly, they will need to know this to design the ICU of tomorrow. Thank you.  If you're interested, these are the caring canine dogs of Memorial. They're employees at a hospital, and sometimes we let them in the ICU.  So we have a couple minutes left at the end here. If anybody has any questions for our speakers, there are microphones in the center here. You can feel free to come up.  We are from Rochester. Thank you for the panel to bring a lot of great examples for design and to change behavior  because ultimately, I'm a big believer that force function is much more powerful than just simple education. So I have two questions. So ICU is not a stand-alone unit.  It really has an upstream-downstream connection with ORs, blood banks, radiology. How do you think about the design from other components of the hospital really connected with this?  This is the first question. The second question, there's another initiative, or not the term is called design thinking.  You know, those folks do a lot of empathy, you know, phototyping, testing. So how do you see that design thinking fits to the design of architect, the physical space,  rather than just the workflow and the processes? Thank you. I think for at least the second part of your question, what we often do are build mock-ups.  I think this touches what you're asking about. And we do it with very inexpensive cardboard panels with cutouts of paper that represent  electrical outlets and medical utilities and so forth. And bring in all the different players that work in the unit. And then we make changes from that.  You would think that most ICUs are about the same, right? Well, there's a lot of variation. Depends on specialty, depends on the past history of everyone that works there.  What they've seen before and what they've used before. So it's, but it's a way of, if you're going to build 24, 36, 48 critical care rooms at  an outrageous cost, you really want to get it right. You don't want to do one wrong and then duplicate that a lot of different ways.  And going back later to make changes is very difficult to do. First question, how do you connect the URIs to the server line? Very true. Very true.  So how do you see the big picture? How does it fit in? Because EV design, OR design, elevator, where do they go? Correct. Correct. Good question.  And in a simple response, that's basically design. That much of those overall organizational, the building organization, those get set very early.  And that gets as much focus as the detail does later to make sure that the circulation works both vertically, horizontally, onto the site, within the site, how people will  move, how materials will move, how patients will, today I went to a meeting that was in  this room this morning on using critical care units for recovery, immediate recovery, post-surgical, which we've done a lot of those. Is that valuable or not valuable?  That was their topic, pros and cons. But for the architects and for the physicians and the nurses, you're tracking all those  different paths of movement and make sure that it works as it needs to, as it should. Charles, let me also answer that. Is this on? Yes, it is. Yeah.  Importantly, a ward in a hospital later on is renovated into an ICU. So the original architect's design, which may have taken care of elevators and operating  rooms and PACUs and ICUs and labs and pharmacy and a logical thing, that logic is gone because you're taking a different area, which didn't fit into the original construct.  So all you could do is the best you could do within those things. Okay, thank you. Harry Anderson from St. Joe's Ann Arbor, and I guess this can go to anybody on the panel  up front, but building an ICU or building a building is an expensive construct. And so how much time do you spend going back to look at some of the things that you created?  Or Neil, you kind of brought this up in terms of future proofing or making your building be usable 10, 15, 20, 30 years down the road.  How do you review kind of what you put into place continuously to see how medicine or buildings are changing with regards to what needs to be done?  Let me answer the question the following way. I have looked for years to see if any architect company went back to anything they built and  published a five or 10 year retrospective about what they built. I have yet to find that. It certainly does not exist in the ICU literature.  However, today we're finishing an article looking at 13, we opened in 06, 07, we're doing an article that is a case study that looks at all the things we had when we opened  and everything we have changed in the interim. And we continue to manipulate, update, whatever the ICU.  So I think we'll put that article out and it'll go through many years of updating an environment and what failed and what worked.  So for example, eGlass, we're now on generation three. My friends in Utrecht came to talk to me yesterday, Joseph Kasuglio, and he said, you know, Neil,  I'm having problems with the eGlass. And he only got the eGlass because I came to you. And I said, Joseph, you got to call me because we're on now generation three.  There's something that fails over time. And we learned after the first cost that we took long term warranties going forward and local vendors.  And now we're extra UV coating the outside glass. But to find that in an article that goes through all of these things is not possible today,  but it will be possible in a few months. Hi, thank you. I'm Sebastian Romignano. I'm with Penn Medicine and I'm a nurse manager in a surgical intensive care unit.  And I've been able to experience many different types of units. But I've always been very interested in the one slide where you showed all the different  options of, you know, the straight line, the square, the circular units. I'd be very interested to know if nursing satisfaction scores, employee engagement,  and provider burnout is tied to specific types of units. And has there been follow up in what a unit design change can do to the culture of a unit in the long term?  I guess this one's for me, right? That's a great question. And I think that it's an opportunity for us to look into, I think, oftentimes, the new  design comes and we're forced to work with it. And we don't know what we thought was going to work as it was being designed doesn't because  we're humans and the human factor approach about how do we interact with each other and what happens.  We're seeing that our unit is a surgical ICU and it was alcoves outside of every patient room. And we're finding that nurses don't like to be there.  They want to be elsewhere where the rest of the staff are. They don't like to be assigned to the patients that are down the hallway over here, far away from that.  And so those things do lead to burnout. But the problem is, I'm not sure that we're asking those questions.  And so I think there's a shift in our culture and our ability to think about what impact this has on the staff and asking those questions. Art? Arthur St. Andre.  I'm not sure this is on anymore. So Arthur St. Andre, could a couple of you comment on the concept of the universal room, probably for some of the audience to find it?  I know of situations where people have really felt that's the way to go and haven't necessarily felt that way after it's been built.  Since I hear about it occasionally, so I'd just like to hear what the collective knowledge and experience is about universal rooms. I'll provide on that.  The definition of that is a patient room and a unit which can function either as a medical  surgical floor room or unit or a critical care bed patient room unit or part of a building. It's always a topic that comes up.  It is very enticing for a hospital administrator to have and believe in that flexibility, which is quite possible.  But if you program, create that list of spaces that are required for both critical care and med-surg, and sometimes they are duplicative and often they are not.  There may be spaces required in the facility guidelines, which most states use as their standards for health care.  There will be spaces required and very prescriptively for medical surgical that you will not find in the ICU guidelines out of the same facilities guidelines institute.  When I have done absolutely excruciating parallel programs, what I have found is if you want the universal type of unit, it will add 15 to 20 percent more square footage to do it.  That's because you are accommodating both medical surgical as well as critical care. So it adds square footage, therefore it adds cost to the unit.  Now, some hospital administrators will believe that's cheap for the flexibility that it gives you. But it's very complex to do and to do well. That part is absolutely true.  As you on the panel know, I have been involved with some of this for a long period of time. A message I believe we should give to our clinicians that all of you I know espouse  to is to do your utmost to get clinicians involved early, early on in the thoughts relative to design in that those who are typically involved from the clinical side may not be  those who live in the space. Too many mistakes are reasonably easy to avoid if designers through the administrative leadership  really make sure that we have those who are actual participants in care actually contribute  to design. That's a great point. But it isn't the designers, maybe outside people that could do that task to make sure.  So the hospital administrators, or what I'll call the bank, they will have their perspective.  So if you have prescriptive hospital administrators that say this is the space, this is the square  footage, this is what we're doing, and the ICU leadership, clinical leadership doesn't get in until later, that's a big problem.  The flip side is to be, I'll use the word aggressive, and try and get in right at the  ground level and work very hard with the architects, the hospital bean counters, other administrators,  so on, to make sure the clinical needs, family needs, staffing needs are met in the ICU design.  But that is a challenge. I was fortunate, both in my prior life at the VA Bronx Center Memorial, to be essentially allowed in.  But I have friends that huge ICUs were built in their organizations, and the hospital administration  essentially said, this is it, do your best. But this doesn't work, well, why don't you tell us? Well, we couldn't tell you because we didn't know what you were doing.  So to be fair in the conversation, it really matters the environment you work in, and what the critical care team can make of that environment.  But if the critical care team is going to engage, they must become quite knowledgeable on the topic.  You can't engage in a process and even seek to manage or co-manage the process if you are not knowledgeable on the issues revolving around ICU design.  The point has already been made once or twice, but to emphasize it, oftentimes if you do get involved, much of the time and energy goes into the design of the room.  And in experience, it's the workflow outside of the room and the space to accommodate others where some of the difficulties actually arise.  So just the hint, if you will, is to make sure you spend an awful lot of time on that  and projecting how you see care might be delivered in the future. An example would be APPs who didn't necessarily exist for when many of these units were designed  and space wasn't put into place to accommodate all of their needs. As we change our care paradigms, we're going to have to really understand the impact of future design.  Just to quickly answer that, we ended up having to take on-call rooms and convert them to an APP lounge for a team that didn't exist on day one, and we never thought would grow  to the size they are. Thank you very much, everyone, for your attendance and for the great discussion. Have a good rest of the afternoon.

Video Summary

The session titled "Quality and Safety in the ICU: How Facility Design Influences Clinical Outcomes" discussed various aspects of ICU design and how it can impact patient care and outcomes. The speakers discussed the importance of patient-centered care, safety issues, infection prevention, lighting, efficiency in patient care delivery, timeliness, and equity in size and layout. They emphasized the need for good design elements that help promote patient healing, such as a quiet and distraction-free environment, adequate space for families, and easy access to emergency equipment. The speakers also highlighted the importance of considering noise levels in the ICU, as high noise levels can have negative effects on the patients and staff. They discussed the impact of noise on patient outcomes, including increased heart rate, blood pressure, and disruptions to sleep. The speakers also discussed the importance of privacy in the ICU, both in terms of physical privacy with patients needing their space and the importance of digital privacy to protect patients' medical information. They also touched on the role of technology in the ICU, including the use of artificial intelligence and machine learning to improve patient care and outcomes. The speakers also discussed the importance of considering disaster planning and threat management in ICU design, as well as the concept of future-proofing, which involves designing facilities that can adapt and remain functional in the face of changing technologies and healthcare needs. Overall, the session emphasized the importance of thoughtful and evidence-based design in creating an effective and safe ICU environment that supports high-quality patient care.

Asset Subtitle

Quality and Patient Safety, Administration, 2020

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2020 Critical Care Congress held February 16-19, 2020, in Orlando, Florida, USA.

Learning Objectives

Review key and novel recommendations for healthcare designs in the literature to date
Interpret the current literature linking ICU design to clinical outcomes as they relate to reducing infection and errors
Explore important lessons from more than 25 years of ICU Design Award winners
Describe how patient room and unit design promote and enhance family presence and social support for the patient

The Growing Evidence Relating ICU Design to Outcomes

Sandy M. Swoboda

Lessons From More Than 25 Years of ICU Design Award Winners

Charles D. Cadenhead

What Has Been Learned and Changed in the Ten Years Since Winning the SCCM Award

Neil A. Halpern

Meta Tag

Content Type Presentation

Knowledge Area Quality and Patient Safety

Knowledge Area Administration

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Membership Level Professional

Membership Level Associate

Tag Communication

Tag Informatics

Tag Patient and Family Support

Year 2020

Keywords

ICU Design

Patient-centered Care

Infection Prevention

Noise Levels

Patient Outcomes

Privacy in ICU

Technology in ICU

Disaster Planning

Future-proofing

High-quality Care

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